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Die Postoperative Kontinuierliche Peritonealspülung Mit Ringer-Lactat-Lösung Zur Prophylaxe Des Adhäsionsrezidivs Nach Laparoskopischer Adhäsiolyse

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Die Postoperative Kontinuierliche Peritonealspülung Mit Ringer-Lactat-Lösung Zur Prophylaxe Des Adhäsionsrezidivs Nach Laparoskopischer Adhäsiolyse Aus der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe (Direktor/in Univ.-Prof. Dr. med. Dr. hc. Wolfgang Straube) der Medizinischen Fakultät der Ernst-Moritz-Arndt-Universität Greifswald und der Abteilung für Gynäkologie (Teamchef PD Dr. med. habil. B. Bojahr) der Klinik für Minimal Invasive Chirurgie in Berlin Die postoperative kontinuierliche Peritonealspülung mit Ringer-Lactat-Lösung zur Prophylaxe des Adhäsionsrezidivs nach laparoskopischer Adhäsiolyse Eine retrospektive Untersuchung Inaugural-Dissertation zur Erlangung des akademischen Grades Doktor der Medizin (Dr. med.) der Medizinischen Fakultät der Ernst-Moritz-Arndt-Universität Greifswald, 2005 vorgelegt von: Martin Gerhard Wilhelm Hänel geb. am: 20. September 1971 in: Marburg an der Lahn i Dekan: Prof. Dr. rer. nat. Heyo K. Kroemer 1. Gutachter: 2. Gutachter: 3. Gutachter: Ort, Raum: Tag der Disputation: ii Inhaltsverzeichnis 1 Einleitung..................................................................................................................... 1 1.1 Adhäsionen und ihre Bedeutung............................................................................ 1 1.2 Pathogenese peritonealer Adhäsionen.................................................................. 1 1.2.1 Heilung von Peritonealdefekten........................................................................... 1 1.2.2 Entstehung von Adhäsionen................................................................................ 2 1.2.3 Ursachen von Adhäsionen................................................................................... 3 1.2.3.1 Kongenitale Verwachsungen........................................................................ 3 1.2.3.2 Operationen im Bereich der Bauchhöhle...................................................... 3 1.2.3.3 Fremdkörperreaktion..................................................................................... 4 1.2.3.4 Infektionen.................................................................................................... 4 1.2.3.5 Endometriose................................................................................................ 5 1.2.3.6 Ischämie........................................................................................................ 5 1.2.3.7 Blutung.......................................................................................................... 5 1.3 Klassifikation von Adhäsionen............................................................................... 5 1.4 Prävalenz von Adhäsionen...................................................................................... 5 1.5 Folgen von Adhäsionen........................................................................................... 6 1.5.1 Gesundheitliche Folgen....................................................................................... 6 1.5.1.1 Schmerzen.................................................................................................... 6 1.5.1.2 Ileus.............................................................................................................. 6 1.5.1.3 Sterilität der Frau........................................................................................... 7 1.5.1.4 Komplikationen bei Folgeeingriffen............................................................... 7 1.5.2 Wirtschaftliche Aspekte....................................................................................... 7 1.6 Möglichkeiten der Therapie von Adhäsionen........................................................ 8 1.7 Möglichkeiten der Prophylaxe von Adhäsionen.................................................... 9 1.7.1 Allgemeine Maßnahmen...................................................................................... 9 1.7.2 Adjuvante medikamentöse Maßnahmen............................................................. 9 1.7.2.1 Systemische Prophylaxe............................................................................... 9 1.7.2.2 Topische Prophylaxe................................................................................... 12 iii 1.7.2.2.1 Flüssige Barrieren................................................................................ 12 1.7.2.2.2 Feste Barrieren..................................................................................... 15 1.7.2.2.3 Lavage mit Zusatzstoffen/topische Wirkstoffe...................................... 16 1.8 Adhäsionen, Adhäsiolyse, Schmerzen und Adhäsionsprophylaxe...................18 1.9 Fragestellung.......................................................................................................... 19 2 Material und Methode............................................................................................... 21 2.1 Material.................................................................................................................... 21 2.2 Methode.................................................................................................................. 23 2.2.1 Adhäsiolyse und Vorbereitung zur Spülung....................................................... 23 2.2.2 Spülung............................................................................................................. 24 2.2.2.1 Postoperative Klarspülung.......................................................................... 24 2.2.2.2 Adhäsionsspülung....................................................................................... 24 2.2.2.3 Klar-/Adhäsionsspülung.............................................................................. 25 2.2.2.4 Septische Massivspülung............................................................................ 25 2.2.3 Auswahl des Patientenguts............................................................................... 25 2.2.3.1 Einschlusskriterien...................................................................................... 25 2.2.3.2 Ausschlusskriterien..................................................................................... 26 2.2.3.3 Selektion des Datenmaterials..................................................................... 26 2.2.3.4 Detailsuche................................................................................................. 28 2.2.3.5 Aufteilung in die Kollektive „mit Spülung“ und „ohne Spülung“....................28 2.2.4 Spülarten, Spüldauer und Anzahl der Spüldrains.............................................. 29 2.2.5 Objektivierung der Adhäsionen.......................................................................... 29 2.2.6 Objektivierung des intraoperativen Adhäsiolyseerfolges................................... 32 2.2.7 Objektivierung des Adhäsionsrezidivs............................................................... 32 2.2.8 Objektivierung des tatsächlichen Adhäsiolyseerfolges...................................... 33 2.2.9 Beobachtungen zum Schmerzempfinden.......................................................... 33 2.2.10 Beobachtungen zu Operationsindikationen und Diagnosen............................ 34 2.2.11 Beobachtungen zu den einzelnen Operateuren.............................................. 34 2.2.12 Beobachtung zum zeitlichen Verhalten von Adhäsionen................................. 34 2.3 Verwendete Software............................................................................................. 35 iv 2.4 Statistische Tests................................................................................................... 35 3 Ergebnisse................................................................................................................. 36 3.1 Ergebnisse des Auswahlprozesses..................................................................... 36 3.2 Altersverteilung der Kollektive............................................................................. 37 3.3 Zeitabstände zwischen den beiden Operationen................................................ 38 3.4 Dauer der Operationen.......................................................................................... 39 3.5 Patientinnen mit Voroperationen bei der ersten Operation............................... 40 3.6 Indikationen und Diagnosen der ersten Operation............................................. 40 3.7 Schmerzen.............................................................................................................. 45 3.8 Auswertung der Spülarten, Spüldauer und verwendeten Drains...................... 46 3.9 Auswertung der laparoskopischen Adhäsiolyse................................................ 50 3.9.1 Adhäsionsscore präoperativ.............................................................................. 50 3.9.2 Indikationsabhängiger Adhäsionsscore............................................................. 53 3.9.3 Adhäsionsscoreverlauf...................................................................................... 55 3.9.4 Effekt der Adhäsiolyse auf den Adhäsionsscore................................................57 3.10 Adhäsionsrezidiv.................................................................................................. 58 3.11 Tatsächlicher Adhäsiolyseerfolg........................................................................ 59 3.12 Indikationsabhängiger Adhäsiolyseerfolg......................................................... 61 3.13 Erfolg der Adhäsiolyse in Abhängigkeit vom Operateur.................................. 62 3.14 Untersuchung zum zeitlichen Verhalten von Adhäsionen..............................
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